Pulling Out Is In

"What birth control method do you use?" I'll ask every new patient. Some will guiltily answer, "Nothing." "Not even condoms, or withdrawal?" I'll reply. "Oh, yeah, he pulls out. But we don't use real birth control."

The withdrawal method of contraception (also known as coitus interruptus, or pulling out before ejaculation) has never received much respect from doctors. Withdrawal as a method requires awareness of imminent orgasm by the guy - and the ability to pull out in time. It's a method classified as "coitally dependent" - you need to use the method when you have sex instead of planning ahead of time...and lust doesn't always allow for clear thinking in the moment. And pre-ejaculatory fluid, or pre-cum, has long been though to contain a small amount of sperm, enough to render the pulling out action virtually useless at preventing pregnancy.

Withdrawal often isn't even considered birth control by its practitioners. It's commonly considered to be better than no method of birth control - but not by much. Many women consider it a last resort, during unplanned sex without a condom, or during a month with missed pills or a forgot-to-replace ring. And even more women may use withdrawal as a back-up to another method. It's estimated that at least one-third of women use withdrawal for at least some acts of intercourse.

Researchers have difficulty estimating exactly how many couples use withdrawal as a method, since if they're not directly asked, women don't often report it - making it difficult to assess its effectiveness. But it may be time to take another look at withdrawal as a viable birth control option. Why?

• It's actually pretty effective. Compare pulling out to condoms - both methods are very effective when used perfectly (about 4% vs 2%)...and less good in real practice (about 18% vs 17%). Scary numbers for condom users, maybe, but many couples rely on condoms alone at least sometimes.
  
• Not all sex is planned. And when sex is gonna happen, and there's no condoms around, it's the only option available at the moment (until plan B the next morning).
  
• Pre-cum may be clear, after all. Recent studies indicate that pre-ejaculatory fluid does not contain sperm (your high school boyfriend may have been right!)...increasing the effectiveness of the method when he withdraws in time.
  

The usual disclaimers: Withdrawal will not protect you against STDs - only condoms will. It's not nearly as effective as an IUD or hormonal methods of birth control. And it puts the responsibility for her not getting pregnant squarely in his hands (or his hips, as it were), which many women may not feel comfortable with. But as a back-up to another method, or for infrequent or surprise sex, consider pulling out to be much better than nothing at all.

Photo credit: zen

The Air Down There

Dear Dr. Kate,

I was just wondering if all vaginas smell the same. It sounds really weird but I am so insecure about the smell/taste of mine. My boyfriend does not seem to mine going down there, so I figure it must not be bad, but I can't help but think mine smells wrong or different from other women's. I can smell mine after I wipe and on my dirty underwear... I'm just not sure if that is normal or not. I have been tested for STD's and everything, so why does mine have such a distinct scent/taste? Can other people smell it too?

Pungent V

Dear Pungent,

No, all vaginas don't smell, or taste, the same...but they do all smell. Every woman has a different musky scent, and we tend to be very attuned to our own smell, even when no one else is aware of it. No one smells you through your clothes; I will occasionally notice a patient's scent when she's undressed (and I'm doing her Pap smear), but never when she's dressed. Odor tends to come from sweat - the vulva and vagina have sweat glands, like elsewhere on your body. And the scent may change as our menstrual cycle progresses, in response to hormones, or at the end of the day. Noticing vaginal odor, if it's your normal one, does not mean you don't have good hygiene or (god forbid) should start douching. No need to buy those scented sprays, either - the chemicals may give you a bad reaction, or lead to copious amounts of discharge. Your vagina should smell like...a vagina.

Yes, sometimes odor can signify bad things - vaginosis, a lost tampon or condom (don't laugh, it happens), or a bit of urine leakage. But if you've been checked out by your gyno, then rest assured that your scent is healthy. And as your guy's enthusiasm for oral shows you, you're all the sexier for it.

Photo credit: net_efekt

The Top 5 Reasons You Shouldn’t Douche

1) Douching can make odor and discharge worse. Ironic, since these are the most common reasons women douche in the first place. If you have an infection, douching promotes even more bacterial growth, so you wind up feeling worse than when you started.

2) Douching can’t prevent STDs. It doesn’t clean out the harmful bacteria, just washes away the good ones, which actually increases your risk of infection.

3) Douching may cause pelvic inflammatory disease. It pushes the bacteria into your uterus, where they can travel to your tubes and wreck great havoc. Women who douche have over a 70% greater risk of PID compared with women who don’t.

4) Douching is not effective birth control. In fact, it just lets more sperm surf their way into your cervix. But, I don’t have to tell YOU that, right?

5) Douching may cause ectopic pregnancy. And while the sperm are surfing north, they’ve got a straight shot for your tubes, giving you a 75% higher chance of having a pregnancy land there.

Don't get swayed by product-pushers who imply that you need their chemicals up your wahoo to be healthy. The vagina is a self-cleaning organ, when left alone to do her thing.

Photo credit: Muffet

REALLY Sweet Dreams

Dr. Kate,

I'll just cut right to the chase: I have orgasms in my sleep, what can be called "wet dreams." When I dream something erotic (even if it's just my husband & I having sex), not only do I become aroused, but I have actual orgasms. I would say I have several wet dreams a month.

Now, I'm not complaining -- it's kind of awesome, to be honest! -- but I want to know how common this is amongst women? Because I've never heard of women having wet dreams. Men, yes...women no. Although, my own husband hasn't ever had a wet dream. I find that strange, because I always thought that men are the only ones to have them.

So what's the deal?

Sexy Sleeper

Dear Sleeper,

Believe it or not, you're not alone. The 1950s sex researcher Alfred Kinsey estimated that 40% of women will experience an orgasm while asleep before the age of 45. And these unconscious orgasms seem to be more common as we get older (something to look forward to!). The going theory is that during sleep, our normal inhibitions don't hold us back, so things that we find erotic--even if disturbing or "forbidden"--will arouse us in a way that wouldn't happen while we're awake. And women may climax faster when asleep, for the same reason. For good or bad, these orgasms are not voluntary or under conscious control - so there's not much point in trying for one (or trying to prevent them).

Having orgasms while sleeping is not a sign of sexual dysfunction, and they're not a comment on the quality (or quantity) of your sex life. While there's some crazy psychoanalytic research out there about what sleep orgasms signify, I think they're just a sign of a highly tuned sexual system, one that's built for our pleasure round the clock. So enjoy!

Best of health,
Dr. Kate

Why Pantiliners Are Evil

Sometimes a solution can create an even bigger problem. M. came into my office on Monday, worried about her increased vaginal discharge. She had started a new birth control pill several months earlier, and was overall happy with it. But she had noticed several episodes of spotting, and had taken to wearing pantiliners every day. M.’s spotting had stopped, but her pantiliner habit continued. She now has noticed more—and daily—discharge, and fear she may have an infection.

With apologies to Always et al, pantiliners are the bane of a vagina’s existence. Yes, they’re perfect for light flow days during your period when a tampon is not needed. And they’re great after a bout of weekday-morning sex, when you still feel drippy but need to get to work. But there’s no need to slap one on your undies every day. Your vagina is self-cleaning, and a certain amount of discharge (and even odor) are totally normal. Some women, though, use daily liners to “catch” their discharge to “protect” their underwear. Then their vagina can’t breathe (could you, through that weave?), which actually increases the amount of discharge, starting a vicious cycle. Chemical irritants like douching, by the way, make it all worse.

We have this notion that we need to be bone-dry, all the time (except if we’re aroused, then we can’t be too wet). But a little discharge on your vulva is okay—moisture keeps you from sticking or chafing. So don't wear liners to protect your panties - wear panties to protect your clothes (which is actually what underwear is for). Just change them during the day if you feel the need.

Photo credit: Nena P. Love

Girls Just Wanna Have...More Sleep

Dear Dr. Kate,

I am a 27 year old woman. I have four children and have been very happily married for ten years. My problem is that I have no sex drive whatsoever. I have tried almost everything except pills which I want to stay away from. I know four children sounds like a lot of work and it is but I stay at home with them so it's not as stressful if I was working and being mom. But at the end of the day no matter how much I rest during the day or how many days a week I try not to do to much but just let my body rest, I still have no desire for lovemaking. It has been like this for nine years now after I had my first child. I went to several different doctors and they all tell me a different thing. Anything from over-working myself to being to stressed out. One doctor said I needed to wait at least one year for my hormones to get back to normal. There is at least two years difference between all my children and three between my second and third and still I have nothing. My husband has truly truly been great about this whole thing but it's very frustrating to me. We still have sex but it's just not the same anymore. I don't expected to be perfect every time but at least sometimes. I just don't know what to think anymore or what to do. Can you help???

Thank you,
Tired

Dear Tired,

Of COURSE you're tired. I have a 3-month old at home, and it's more tiring than med school and internship put together...and I only have one child. And you've been a mom for awhile, now. It's not your hormones - it's your life that's different after kids. But cliches aside, sex doesn't have to stop after parenthood begins.

This may sound strange, but I want you to think about why you want to have sex. We all have sex for many reasons, and there may be other things that you can do to also meet these wants:

• You want to feel close to your husband. I'm glad he's so understanding; make sure you're getting enough time for the non-sex stuff, like hugs, time on the couch watching a movie, and even making out.

• You want to feel like a woman, not just a mommy. I'm sure there are days that you feel like a pair of breasts (if you're breast-feeding) with a wallet and a set of car keys.

• You think you should. In survey after survey, people in the US roughly break down into thirds: 1/3 of us have sex twice a week, twice a month, or twice a year. So there's no "normal" amount of sex to have.

• You want a penis in your vagina. Okay, there's no getting around this one.

Now you can think about why you think you don't want to have sex these days. Think beyond the fatigue...

• You're out of touch with your body. It's funny how the product of sex (your little ones) can make you feel asexual. You may need to take time to see yourself as attractive and sexy again, whether it's as simple as perfumed lotion or a push-up bra, or making time to go to the gym to feel strong in your body. And masturbation may help as well - a few easy orgasms with a great vibrator may make you want to come with your husband even more.

• You're afraid of getting pregnant. Your gyno can talk with you about birth control options (the IUD may be perfect) so you don't need to think about having #5.
  

• You're afraid the kids are going to walk in. Nothing kills the mood faster than a little voice at the end of the bed asking, "Mommy, what is Daddy doing?" If you can get good child-care, take an evening in a hotel with your hubby; even if it's just a few hours, you can just be the two of you for a time.
  

• You don't have time. First, there's getting you and your husband in a room, alone, and awake. Then there's foreplay, a good sex prerequisite. Not that quickies are a bad thing, but women on average need 20-30 minutes of good foreplay before sex is comfy. So there's nothing wrong with needing/taking this much time.
  

• Sex outright hurts. Especially when you haven't had sex in awhile, or if you're not getting enough foreplay. If your local drugstore is lacking, or you don't have time to shop, check out the lubricants at Good Vibrations and Babeland.
  

• Sex isn't good for you. Even if it doesn't hurt, sex that doesn't lead to semi-regular orgasms isn't that appealing. So if intercourse isn't your ticket to paradise, make sure that you're getting enough manual/oral/vibe stimulation before/during/after intercourse.
  

There's never an easy answer for not wanting sex...and there's no pill that will fix this ill, either. Think about what has changed, what you think may make it better, and talk with your husband about it. The two of you together will figure out a way to get the fire back.

Best of health,
Dr. Kate

Photo credit: obo-bobolina

I Don't Want To Go To The Gynecologist!

It's sometimes tough to have a job where no one is happy to come see you. Yes, I have a good relationship with my patients, and there's even a wait to get an appointment with me. But even my long-timers sometimes grit their teeth at the thought of coming in for their annual exam. Through talking with patients--and looking at search terms from my blog readers--I've identified 4 major barriers to getting a gyn exam:

• Modesty. You may know that your doctor looks at boobs and vaginas for a living, but it may not make it any easier to get naked and put on one of those awful, one-size-fits-nobody paper gowns. You worry about how you look and how you smell. You wonder if the doctor notices that you haven't shaved. You fear that she's comparing you - in any way - to any other patient.
  
• Fear of pain. Especially if you haven't been to the gyno in awhile. Thoughts of the speculum placement - the cramp with the pap smear - the achiness with the internal exam...it's enough to make anyone's knees lock together.
  
• Fear of arousal. Your arousal - what if you get turned on during the exam?? And the doctor's arousal - after all, don't straight men and gay women get turned on looking at a naked lady?
• Fear of bad news. Bad enough you have to endure the indignity of an exam, but then you need to wait a few weeks for your lab results to hear that you're in good health...or not.

No wonder it sucks to come see me! But here's what I think about each of these things:

• You're just like every body else. You most likely look and smell completely normal. I don't care if you're shaved, or waxed, or powdered, or toned, or not. I do care if you're pierced, only so I can advise you on safe piercing practices. While I care about all aspects of your personality when we're talking, when you're undressed I'm only caring about the square inches of skin I'm examining. And that's all I see at that moment.
• I really don't want to hurt you. First, because I want you to have a good experience. But if you're in pain and pulling away, I can't examine you as well as I need to. So the exam goes better for both of us if you're comfortable.
• There's nothing sexy about a GYN exam. I'm a straight woman, and I have gyno friends who are men and who are lesbians. We all agree that the clinical environment of a gynecologist's office--the bright lights, the creaking stirrups, the frigid temperature--does not breed sexy thoughts. And I've never had a patient get aroused, much less climax, during an exam.
• Knowledge is power. And knowing even the worst, is better than being in the dark. A good gyno will deliver your test results in the way that works best for you--whether that means a return visit to talk about them in person, or a phone call, or even an email.
  

So what can you do about all of this? Go to a gynecologist who makes you feel at ease. Tell him or her your concerns about the exam, and see if they'll work with you to ensure your maximum comfort. And know that you're doing the best thing possible for your health...and you don't have to go again till next year.

Photo credit: maigh